The findings of the coronial Inquest into the deaths at Westfield Bondi Junction on 13 April 2024 highlight the complexity of severe mental health challenges and the critical importance of coordinated, well-resourced systems of care – particularly accessible, community-based mental health and psychosocial supports that provide continuity, early intervention and recovery-focused care.

Mental Health Coordinating Council (MHCC) acknowledges the release of the findings and recommendations from the coronial Inquest into the deaths at Westfield Bondi Junction on 13 April 2024. We extend our continued sympathies to the families and loved ones of those who lost their lives, and recognise the profound and ongoing impact of this tragedy and the inquest process on the families, witnesses, workers and the broader community.

It is important to state unequivocally that living with a mental health challenge does not mean a person is violent. Instead, they are far more likely to experience harm, discrimination and systemic disadvantage than to cause harm to others.¹

The inquest makes a number of findings and recommendations, with 11 of the recommendations directly relevant to mental health policy, clinical care and the interface between health and police responses.

Key findings relevant to mental health

The Coroner calls for:

• A review of the offender’s prior care (Recommendation 1)

• A comprehensive update of the RANZCP schizophrenia clinical guidelines, including explicit guidance on:

  • relapse risk

  • treatment-resistant schizophrenia

  • indefinite monitoring where medication is discontinued
    (Recommendations 2–3)

• Shared-care guidelines between psychiatrists and GPs for chronic and treatment-resistant schizophrenia, including:

  • clear handover processes

  • relapse-warning education for families

  • explicit guidance on risk considerations (e.g. driving, machinery, weapons)
    (Recommendations 4 & 6)

• Establishment of a working group with police to clarify psychiatrists’ roles in firearms licensing assessments
  (Recommendation 5)

System-level reform recommendations

The inquest also calls on the NSW Government to pursue broader system reforms, including:

• Expanding short- and long-term supported housing linked to mental health care

• Obtaining advice on the decline in mental health outreach services in NSW, including:

  • current and future demand

  • workforce requirements

  • timeframes needed to achieve reform

• Ensuring clinicians have access to clear deprescribing guidance
  (Recommendations 7–8)

Police–mental health interface

Several recommendations focus on improving coordination between police and health systems:

• Amending Queensland’s Public Health Act (s157B) to:

  • include “immediate risk of serious harm to others” (not only self-harm)

  • clarify the definition of “serious harm”
    (Recommendation 9)

• Strengthening Mental Health Intervention Coordinator roles within Queensland Police, particularly in the Darling Downs region
  (Recommendation 10)

• Supporting broader rollout of co-responder models in NSW, pairing police with mental health clinicians to improve crisis responses and pathways to care
  (Recommendation 11)

The role of community-based mental health care

The inquest findings reinforce the importance of systems that support people before crisis and provide continuity of care across settings.

We continue to strongly advocate for accessible, well-resourced, community-based mental health and psychosocial supports as central to wellbeing, recovery and positive long-term outcomes for people living with mental health challenges.

There is strong evidence demonstrating the effectiveness of trauma-informed, recovery-oriented, community-managed programs:

• Community Living Supports have been shown to:

  • reduce mental health-related hospital admissions by 74%²

  • reduce average length of hospital stay by approximately 75%²

• Prevention and Recovery Centres:

  • reduce emergency department presentations by 33–44%³

These outcomes highlight the importance of sustained investment in community-based mental health supports that keep people well and reduce pressure on acute services.

As public discussion continues, we emphasise the importance of evidence-based, responsible commentary that avoids reinforcing stigma or simplistic associations between mental ill-health and harm, and that upholds the dignity, rights and humanity of people living with mental health challenges.

References

¹ https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release

² https://www.health.nsw.gov.au/mentalhealth/resources/Publications/cls-hasi-eval-rpt.pdf

³ https://www.mhcc.org.au/wp-content/uploads/2025/03/Bondi-PARC-Final-Evaluation-Report_March-2025.pdf